A 42-year-old woman presents with 8 months of mucoid diarrhea mixed with bright red blood, tenesmus, and 5 kg weight loss. Colonoscopy reveals multiple sessile and pedunculated erythematous polyps (5–30 mm) with adherent whitish fibrinopurulent caps clustered at mucosal fold apices in the rectosigmoid. Biopsies confirm cap polyposis with hyperplastic crypts covered by fibrinopurulent exudate, without dysplasia. Conservative management with fiber, osmotic laxatives, biofeedback, and topical mesalamine has failed over 6 months. The patient remains symptomatic with persistent bleeding and diarrhea. Which of the following interventions, marked as **A** in the management algorithm, is the preferred next step for this refractory case?
A. Antibiotics alone without biologic or surgical intervention
B. Long-term oral steroids as definitive monotherapy
C. Infliximab or surgical resection for refractory cases
D. Routine prophylactic colectomy regardless of symptom severity
Explanation
Why Infliximab or surgical resection for refractory cases is right
Cap polyposis is a rare inflammatory (non-neoplastic) polyposis of the rectosigmoid that is resistant to standard therapy in most cases. When conservative measures—fiber, osmotic laxatives, biofeedback, topical aminosalicylates, and steroid enemas—fail, the Williams Cap Polyposis Series and WGO Practice Guidelines on Colon Polyposis recommend stepwise escalation to biologic therapy. Infliximab (an anti-TNF agent) is the preferred biologic for refractory or extensive cap polyposis and has produced sustained clinical and endoscopic remission in multiple case reports. Surgical resection (low anterior resection or sigmoid colectomy) is reserved for severe refractory disease, large symptomatic polyp burden, or suspicion of malignancy when medical therapy fails. This patient meets criteria for refractory disease (failure of 6 months of conservative therapy with persistent bleeding and diarrhea), making infliximab or surgical resection the appropriate next step.
Why each distractor is wrong
Routine prophylactic colectomy regardless of symptom severity: Colectomy is not routine or prophylactic in cap polyposis; it is reserved only for severe refractory disease, large polyp burden, or suspicion of malignancy. Premature colectomy is not indicated in this patient and contradicts evidence-based stepwise management.
Antibiotics alone without biologic or surgical intervention: While Helicobacter pylori eradication should be considered in H. pylori-positive patients and may produce remission in some series, antibiotics alone are not the preferred management for refractory cap polyposis. This patient has already failed conservative therapy and requires escalation to biologic or surgical intervention.
Long-term oral steroids as definitive monotherapy: Systemic oral steroids are not standard therapy for cap polyposis and lack evidence of sustained remission. Topical steroid enemas may provide modest benefit, but oral steroids alone are not the preferred approach for refractory disease.
High-YieldNEET PG
Cap polyposis refractory to conservative therapy (fiber, laxatives, biofeedback, topical mesalamine) escalates to infliximab (preferred biologic) or surgical resection for severe/extensive disease.
Williams Cap Polyposis Series + WGO Practice Guidelines on Colon Polyposis
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